1Organ donationStudent’s nameI

1
Organ donation
Student’s name
Institution
Course number
Instructor
Due date

From the podcast , fewer human organs are required by
the people. There is a shortage of organs like kidneys, liver, and
heart. Even the surgery and the transplant itself can be risky
procedures, and the patient or the donor can lose their life too.
The donor and the recipient should have a march of their organs
before the transplant is done (Abbasi et al.2018). This
procedure involves a lot of tests and procedures before the
transplant is done. The donor has to consent by signing
accepting that they are donating their kidneys.
As per the debate in this video, trading the human
organza should be legalized. From the debate, someone brought
up the idea that if the family members are not a match or they
have underlying conditions that they cannot donate any of their
organs to the patient, then the next option that will be readily
available in the buying of the kidney or the organ of interest.
Legalizing trading will be a lifesaver for most individuals who
need an urgent transplant. If the organs are available in the
hospitals, they are visiting, and they can easily get the match of
their kidneys rather than having the tests being done on their
family members, which takes a long time.
References
Abbasi, M., Kiani, M., Ahmadi, M., & Salehi, B. (2018).
Knowledge and ethical issues in organ transplantation and organ
donation: Perspectives from Iranian health personnel. Annals of
transplantation, 23, 292.
ncbi.nlm.nih.gov/pmc/articles/PMC6248176/

Family Medicine 32: 33-year-old with painful cycles
User: Ralph Marrero
Email: [email protected]
Date: March 30, 2022 10:44 PM
Learning Objectives
The student should be able to:
Find and apply diagnostic criteria, risk factors and surveillance
strategies for dysmenorrhea.
Elicit a focused history that includes information about
menstrual history, obstetric history, sexuality and gender
identification.
Describe appropriate components of a complete physical
examination depending on symptoms or risk factors for
gynecological
problems.
Summarize the key features of a patient presenting with
dysmenorrhea, capturing the information essential for
differentiating
between the common and “don’t miss” etiologies.
Describe the initial management of common diagnoses that
present with dysmenorrhea.

Summarize the key features of a patient presenting with
menorrhagia, capturing the information essential for
differentiating
between the common and “don’t miss” etiologies.
Develop a health promotion plan for a patient of any age or
gender that addresses preconception counseling.
Develop a health promotion plan for a patient of any age or
gender that addresses family planning.
Describe the initial management of common and dangerous
diagnoses that present with premenstrual syndrome.
Recognize “don’t miss” conditions that may present with PMS.
Demonstrate active listening skills and empathy for patients.
Demonstrate the ability to elicit and attend to patients’ specific
concerns.
Knowledge
Primary Dysmenorrhea Definition, Prevalence, and Risk Factors
Primary dysmenorrhea is defined as the onset of painful menses
without pelvic pathology. Secondary dysmenorrhea is defined as
painful menses secondary to some additional pathology.
Primary dysmenorrhea is associated with increasing amounts of
prostaglandins. The actual prevalence is unknown but ranges
from 45% to 97% including teens and older adults. Ten to
fifteen percent of people with a uterus feel their symptoms are
severe
and have to miss school or work. Dysmenorrhea accounts for 1-
3 percent of absenteeism or 600 million hours a year.
Dysmenorrhea usually occurs hours to a day prior to the onset
of menses and lasts up to 72 hours. It can also include
symptoms
of headache, dizziness, fatigue, diarrhea, and sweating so a
broad differential may be helpful.
Dysmenorrhea is thought to be secondary to increased
prostaglandin synthesis, leading to uterine contractions and

decreased
blood flow.
Risk Factors for Primary Dysmenorrhea
Mood disorders such as depression or anxiety have been
associated with dysmenorrhea, especially in adolescents. This
may
be a complex association as other factors may be comorbid with
the mood disorder diagnosis, and the cause and effect is
not well-proven. However, there is an association with stress
independently as a risk factor for dysmenorrhea.
There is also an association between tobacco use and
dysmenorrhea.
People who give birth to more children are noted to have a
decreased incidence of primary dysmenorrhea.
Additionally, those who report an overall lower state of health
or other social stressors have a tendency for dysmenorrhea.
These stressors include social, emotional, psychological,
financial, or family stressors.
Primary dysmenorrhea most commonly occurs in menstruating
patients in their teens and twenties. It is notably associated
with ovulatory cycles. Classically, an adolescent will start
experiencing dysmenorrhea one or two years after menarche.
This
is the time it takes naturally for an adolescent to develop
regular ovulatory cycles. The earlier the onset of menarche the
more likely dysmenorrhea may occur.
This means that a detailed history regarding the nature of
menses during adolescence and after children is important. It
will also
be important to ask about birth control and what types have
been used as some can alter the symptoms.
The first-line treatment for primary dysmenorrhea is
nonsteroidal anti-inflammatory agents, such as ibuprofen. Oral
contraceptive

pills may also be helpful as a second-line choice. NSAIDs
inhibit the production and release of prostaglandins but have
long-term
side effects, and oral contraceptives inhibit ovulation, reduce
endometrial proliferation, and mimic the lower prostaglandin
phase
of the cycle. Complementary alternatives can include herbs
(chamomile, ginger, fennel, cinnamon, aloe vera), yoga,
relaxation,
psychotherapy, massage, hypnosis, vitamins E, B, and C,
calcium, magnesium, and acupuncture/acupressure.
Gender
People who are born with a uterus may identify as female or
male. We can therefore identify this population as "female
assigned
at birth," meaning they had a sex assigned at birth as female
based on the genitalia seen, or “person with a uterus” to
© 2022 Aquifer, Inc. - Ralph Marrero ([email protected]) -
2022-03-30 22:44 EDT 1/10
acknowledge the biologic presence of a uterus in someone who
may identify as anything other than female in their life. Please
note that transgender men should not be excluded in this
consideration, for which calling periods “cycles” and utilizing
terminology of a person with a uterus or exam of the pelvis is
more appropriate than “gynecologic.” See below for additional
gender Teaching Points.
Gender and Sexual Identity Questions
It is important to know how your patient self-identifies and to

not make assumptions. To avoid mis-gendering patients, we
recommend asking early in a visit either how they would like to
be addressed and/or what pronouns they use. Common answers
are he/him, she/her, and they/them, but countless other
pronouns exist within the LGBTQ community (lesbian, gay,
bisexual,
transgender, queer/questioning; this also includes a broad range
of sexual, romantic, and gender minorities, and is more
inclusively referred to as LGBTQIA with intersex and
asexual/ally also represented).
Cisgender refers to a person whose sex assigned at birth, based
on genitalia, matches their current gender identity.
Transgender refers to a person who identifies in a different way
than their sex assigned at birth. The terms “assigned female”
and
“person with a uterus” acknowledge that this population may
include people who have a uterus and cycles who do not
identify as
female.
Sex refers to the physical organs present or expected to develop
at birth.
Gender Identity refers to the patient’s identity as male, female,
non-binary or others, and is not the same as sex.
Gender Expression refers to the patient’s presentation as male,
female or non-binary, and can be different from sex or gender
identity.
Non-binary, gender-nonconforming, and gender-expansive are
all terms some patients use to identify their gender as on a
spectrum rather than binary.
Sexual orientation refers to the gender that people have sex
with. This can be different from romantic orientation as people
can be
romantically and sexually attracted to different genders or vary
based on the person or their own identity. It is also important to
consider the anatomy of partners, as a “male” partner may have
a uterus and not a penis, and a “female” partner may have a

penis. This is important for health risks, screening, and
prevention.
For example, if a patient with a pelvic problem stated that they
actually used he/him pronouns and identified as male, you
would
want to use he/him pronouns, despite talking about problems
related to a uterus. You should not assume based on physical
appearance what organs a patient may or may not have, in the
same way, that you cannot know without asking if someone has
had a hysterectomy.
Questioning About Reproductive History
It is good to start with open-ended questions. Some patients
may have had pregnancy outcomes that they are not comfortable
talking about, such as miscarriages or abortions (reported as
SAB, or spontaneous abortion, or TAB, or therapeutic abortion).
This
requires sensitivity, as it may bring up trauma for that patient,
and it may also require specific questions, such as “Tell me the
outcomes of each pregnancy,” or “Any other pregnancies
besides those children you mentioned?”
Normal Pelvic Exam Findings
Unless a person is pregnant, a normal uterus is not larger than
eight weeks in size, approximately the size of a clenched fist. It
is
also mostly flat, not round as you see in some pictures. A
normal uterus may be mildly tender on exam just prior to or
during
menses. A normal uterus can be tilted anteriorly (anteverted or
anteflexed), midline, or tilted posteriorly (retroverted or
retroflexed). An anteflexed or retroflexed uterus may be
difficult to assess for size because of its position. The uterus
should be

smooth in contour around the entire surface area. Serosal
fibroids or large mucosal fibroids may cause a "knobby" feel to
the
uterus.
The uterus should be mobile. The uterus is held in the pelvis by
a series of ligaments on each side. With endometriosis, the
uterus
may become non-mobile because of fibrous tissue sticking to
the peritoneum along these ligaments.
Ovaries are normally 2 cm x 3 cm in size—roughly the size of
an oyster. In an obese person, the ovaries may be nonpalpable.
During ovulation, the ovaries may be slightly larger secondary
to physiologic cysts. Caution should be taken while palpating
the
ovaries since the patient may have a mild sickening feeling.
Mild tenderness on palpation of the ovaries is normal.
Nabothian cysts are physiologically normal on the cervix. These
are formed during the process of metaplasia where normal
columnar glands are covered by squamous epithelium. They are
merely inclusion cysts that may come and go and are of no
clinical significance. While looking at the cervix white
discharge can also normally be seen coming from the os or in
the vagina. If
there are endometrial growths on the cervix or vagina, these
may be bluish.
Vaginal discharge can be normal or abnormal. Normal vaginal
discharge is termed physiologic leukorrhea. This patient has no
symptoms like itching, burning, or foul-smelling discharge. It is
normal to have physiologic clear to white vaginal discharge.
The
volume of discharge may get so heavy that it requires a pad for
comfort; the volume may change during the course of a
menstrual
cycle.
Menorrhagia

Menorrhagia is very difficult to define precisely and is only one
of the terms associated with abnormal uterine bleeding. The
absolute criterion for menorrhagia is blood loss of more than 80
milliliters. Some providers try to use pad or tampon count.
2022-03-30 22:44 EDT 2/10
However, there is variability in the absorption of different pads
and how much blood one has on the pad prior to changing.
Asking
about clots may help, but again not easy to quantify. In fact,
many women either overestimate or underestimate the blood
loss.
Another important criterion is the length of menses. Anything
longer than seven days is most likely menorrhagia.
Metrorrhagia is irregular frequent bleeding but it doesn't have
to be heavy.
Menometrorrhagia is irregular, frequent, and heavy bleeding.
Premenstrual Dysphoric Disorder DSM-5 Diagnostic Criteria
Premenstrual syndrome (PMS) is characterized by physical and
behavioral symptoms occurring in the luteal phase of the normal
menstrual cycle. Symptoms must not be present at other times
through the cycle, and must also cause significant impairment.
Premenstrual Dysphoric Disorder (PMDD), the more severe
form of the disorder, is classified in the DSM-5 as a mental
health
diagnosis.
The patient must have one of the following: marked mood
lability, irritability or anger, depressed mood or feeling

hopeless, or
anxiety and edginess.
The patient must also have one of the following: food cravings,
changes in sleep, a sense of being overwhelmed or out of
control,
decreased energy, anhedonia, and some physical symptoms.
The patient must have a minimum of five symptoms out of the
above groups. How these are expressed may differ based on
culture and social norms. It may be helpful to get the
perspective of other close contacts of the patient.
Preconception Counseling
Never lose a chance to bring up preconception considerations.
1. Vitamin supplementation: Daily supplementation with 400 to
800 micrograms of folic acid is recommended, as many
pregnancies are unplanned. This lowers the risk for neural tube
defects by over 70%. Patients with a history of miscarriage
or fetuses affected by neural tube defects should be counseled
to take a higher dose.
2. Substance use: Substances such as alcohol, tobacco, caffeine,
or other substances (marijuana, opioids, stimulants, etc.)
should be discontinued and/or cut back as much as possible.
Having shared decision making and readiness to assist with
this process is important. Evidence is growing that marijuana
can have detrimental effects on the fetus, even though it is
more widely accepted. We recommend a sensitive approach to
help patients with addiction cut down on substances when
they are ready. Primary care treatment options for opioid use
may include buprenorphine which can lower withdrawal
symptoms in the neonate.
3. Immunizations: Check for live-attenuated immunizations that
must be given prior to pregnancy, such as MMR and

chickenpox. Guidelines suggest giving Tdap during the third
trimester of each pregnancy, influenza if indicated by the time
of year, and testing for rubella immunity if there is not clear
evidence of vaccination with the MMR vaccine. SARS-CoV2
vaccines should be considered given the higher risk of
complications if one who is pregnant develops COVID-19.
There is
emerging data demonstrating the safety of the mRNA vaccines
in pregnancy.
4. Chronic conditions: Get any chronic medical problems—such
diabetes, depression, asthma/COPD, or thyroid disorders—
under control prior to pregnancy.
Safety and Mental Health
Premenstrual syndrome or premenstrual dysphoric disorder may
coexist with additional Axis 1 and Axis 2 mental health
diagnoses. Depression, anxiety, bipolar disorder, and additional
psychiatric diagnoses should be considered, and if concerned,
asking about thoughts or plans to harm oneself or another
(suicidal ideation, homicidal ideation, and/or self-harm or
intent) is
important.
Management
Primary Dysmenorrhea: Presentation and Treatment
In a family physician's office, primary dysmenorrhea in an
adolescent is a common diagnosis.
In a person with a uterus who is under 20 and not sexually
active with the classic history of suprapubic pain the first two
days of
menses, non-steroidal anti-inflammatory medications can be
started without a pelvic exam.

Ibuprofen is the gold-standard anti-inflammatory, but many
other anti-inflammatories have also been proven equally
efficacious
when taken cyclically starting a day or two prior to the onset of
menses and continuing into the first days of menses. Studies
have
noted improvement with diclofenac, vaginal sildenafil,
celecoxib, and naproxen.
Choice of the specific anti-inflammatory to use should be based
on cost and side effects the patient experiences. If anti -
inflammatories are not effective, combination birth control pi lls
(monophasic or triphasic) with medium-dose estrogen are
effective. Hormonal implants, inserts, intrauterine devices,
patches, and rings may also be considered. Some people will
prefer to
avoid hormonal options if possible. Other treatments shown to
be effective include acupressure, acupuncture, and superficial
needling. Medicinal plant remedies may include fennel, vitamin
E, chamomile and thyme, but other side effects should be
considered.
A pregnancy test should be performed in an adolescent or
anyone with a uterus who is sexually active with someone who
has a
penis. Other testing should be added if the patient has any type
of dysfunctional uterine bleeding or pelvic pain outside of the
typical pattern. For instance, consideration of polycystic ovary
syndrome may be considered for irregular menstruation.
2022-03-30 22:44 EDT 3/10
Treatment for Leiomyomas and Associated Symptoms
A Progesterone-releasing intrauterine device (IUD) is an

effective option for reducing menstrual blood flow in those with
menorrhagia secondary to fibroids. Another advantage is that it
can be left in for five to seven years (potentially longer but not
yet
widely accepted). There are potential complications,
particularly during the procedure to place the device, but after
appropriately
discussing these with a patient it is a viable option. In studies,
the progesterone-releasing IUD (levonorgestrel-releasing
intrauterine system) has clearly demonstrated decreased
menstrual flow in those with fibroids. In one smaller study, the
device
decreased overall uterine volume. However, it does not decrease
the size of individual fibroids already in the uterus. Through
decreasing uterine volume and endometrial atrophy, the
progesterone-releasing IUD can also decrease dysmenorrhea. In
people
who hope to maintain fertility for the future yet control their
symptoms now, this is one of the best options with the fewest
side
effects. Irregular vaginal bleeding, especially initially, is a
common side effect of the progesterone-releasing IUD. Other
potential
side effects are lower abdominal pain and breast tenderness.
The risk of uterine perforation is more likely at the time of
insertion.
The risk of infection is within the first 20 days of insertion.
Routine STI testing may be performed prior to or during
insertion with
immediate treatment if any infection is found. Good patient
instructions to monitor for foul-smelling discharge and signs of
systemic infection or perforation are key.
Acupuncture has been used for many pain conditions. Some
studies demonstrate effectiveness for dysmenorrhea without
uterine
pathology when compared to sham or placebo treatments. In

further studies, acupuncture improves the quality of life but
may be
associated with higher health costs for the patient.
Combined hormonal contraceptives would be an effective
option if the patient has not experienced side effects from these
in
the past. Oral contraceptive pills (OCPs) have been proven
effective when used for dysmenorrhea related to anovulation
only
without a structural problem, especially in a patient who needs
birth control. In those with isolated dysmenorrhea, small trials
have demonstrated benefit. However, a meta-analysis of these
found insufficient evidence that oral combined hormonal pills
are
effective for dysmenorrhea alone. The confusion is that OCPs
are often used in structural problems of the uterus that cause
both
menorrhagia and dysmenorrhea. In leiomyoma and
adenomyosis, OCPs decrease blood loss and may decrease
dysmenorrhea by
thinning the endometrial lining. OCPs are commonly known to
patients and providers making them often the initial step in
management. In adolescents, they have the additional benefit of
regulated menses. However, other options that are not oral, such
as the vaginal ring and the hormonal patch, are worth
considering. These may cause less nausea and vomiting as they
bypass the
gastrointestinal system altogether. All types of combined
hormonal contraceptives have a slightly increased risk of
venous
thromboembolism, highest in the first year of use. For this
reason, these types are not recommended in smokers older than
35
years. Specific side effects with the patch may be site dermatitis
in as many as 20% of users. The vaginal ring has risks of
leukorrhea and vaginitis in approximately 5% of patients; the

other types do not. None of these worsen cervical dysplasia or
have
been proven to increase the risk of breast cancer.
Injectable medroxyprogesterone is another potential treatment
for leiomyomas and the symptoms associated with them.
However, recent literature does demonstrate that there is bone
density loss after several years of use. Other side effects may
include weight gain, irregular menses for weeks to months, and
potential mood changes. However, there is no risk of venous
thromboembolism and this can be used in a smoker older than
35. This is a great choice for transgender men as it can help
decrease periods without additional estrogen or a traumatizing
procedure.
Hysterectomy is the definitive surgical option for those with
secondary dysmenorrhea and those with menorrhagia who no
longer desire to bear children. In a meta-analysis, surgery has
been proven to reduce bleeding more at one year than any other
medical treatment. However, medical treatments may have less
morbidity depending on the exact etiology of menorrhagia.
Some
surgeons will offer hysterectomy to a person with a uterus 14 to
16 weeks in size or greater whether or not the patient has
symptoms. Any leiomyoma that is growing rapidly, regardless
of the rest of the uterine exam, may be an indication for
hysterectomy. For a patient who has failed other management,
hysterectomy may be an option. Myomectomy, in which the
clinician removes the leiomyoma but not the entire uterus, is
another surgical option. Consideration of a patient's future
reproductive plans are important in distinguishing these two
options. Other procedural options for dysmenorrhea unrelated to
uterine pathology include presacral neurectomy and uterine
nerve ablation, both via laparoscopy, though there is
insufficient
evidence to recommend those in most cases.
The copper IUD is another effective form of birth control. This
device may stay inside the uterus for up to 10 years. For those

who are not planning any children in the near future, this may
be a viable option for birth control. An advantage of the copper
IUD
is that it has no hormones. However, in people using this, there
is an increased risk of dysmenorrhea and menorrhagia just from
the IUD. It is not a treatment for leiomyomas at all. In this case,
it could potentially make the symptoms worse.
Since all patients undergoing uterine artery embolization must
understand the potential for urgent hysterectomy, consideration
of future fertility is imperative. Some consider this a relative
contraindication. Post-procedure, the patient usually has pelvic
pain
for at least 24 hours, sometimes lasting up to 14 days. "Post-
embolization syndrome" is a group of signs and symptoms that
include pain, cramping, vomiting, fatigue, and sometimes fever
and leukocytosis. Other complications from the procedure to
consider as you counsel this patient are potential ovarian failure
(up to 3% in women younger than 45), infection, necrosis of
fibroids, and vaginal discharge, and bleeding for up to two
weeks. This treatment is usually reserved for those who cannot
tolerate
other hormonal treatments or who do not want those treatments
for other reasons. This procedure is usually performed by an
interventional radiologist. It is not an option for dysmenorrhea
alone or for menorrhagia without uterine fibroids.
Hormonal Birth Control Therapies
Progesterone-Only Intrauterine Device (IUD)
The progesterone-only IUD can stay in place for three to seven
years, depending on which device is used. There may be some
irregular bleeding at the beginning for up to six months. Some
women will stop bleeding altogether, and others continue
having
periods with less bleeding. The IUD is just taken out if the

patient decides to try to get pregnant again. If, after five years,
they
decide they do not want to get pregnant, it can be replaced at
the same visit for another five years.
Progestin Implants
2022-03-30 22:44 EDT 4/10
These are put under the skin and last for three years. They can
cause unpredictable spotting and can also be removed earlier if
desired.
Hormone Patch
The patch is left in place for one week, then the person uses a
new patch weekly for three weeks. No patch is placed during the
fourth week, during which time the person has a period. This
option contains ethinyl estradiol in addition to a progestin.
Caution
should be used to ensure proper placement for absorption and
consideration of the amount of subcutaneous tissue in the area
of
placement.
Medroxyprogesterone Shot
The shot is given every 12 weeks. If a patient on this decides to
get pregnant, it may take a little longer to get pregnant after
stopping the shots than if they used the IUD. It also has a higher
rate of irregular bleeding at the beginning.
Vaginal Ring
The vaginal ring is placed inside the vagina and left for three
weeks. It is removed the fourth week to have a period.

Premenstrual Syndrome Treatment
Danazol is an androgenic medication with progesterone effects.
It lowers estrogen and inhibits ovulation. However, its multiple
androgenic side effects, including weight gain, suppressing
high-density lipids, and hirsutism, limit its desirability among
patients.
GnRH agonists, such as leuprolide, are effective at treating
premenstrual syndrome through ovulation inhibition. However,
their
anti-estrogen effects, including hot flashes and vaginal dryness,
make these not as popular.
Oral contraceptives are an effective treatment for dysmenorrhea,
anovulation, and in some cases menorrhagia. While not
always effective for premenstrual syndrome, they are a good
place to start. It would be appropriate to try this in a person also
needing birth control. One study demonstrates potential
improved effectiveness by decreasing the placebo pills to four
days from
seven. Additionally, pills can be taken for sequential cycles,
skipping the placebo week, to reduce the frequency of
menstruation
and, theoretically, the rate of PMS/PMDD.
Selective serotonin reuptake inhibitors (SSRI) during menses
are an effective treatment of PMS, especially if severe mood
symptoms predominate. There are three effective regimens for
SSRI use. One regimen is continuous daily treatment. Another
is
intermittent treatment, which is just as effective as a daily
treatment for decreasing both psychological and physical
symptoms
during menses. There are two types of intermittent treatment.
One method is to start therapy 14 days prior to menses (luteal
phase of cycle) and continue until menses starts. The second
method is to start on the first day a patient has symptoms and
continue until the start of menses or three days later. Many

randomized trials have used fluoxetine and sertraline.
Venlafaxine can
be used as well. Lower doses are effective. If one medication
does not work, another in the same class should be tried prior to
considering the treatment a failure. Follow-up should occur
after two to four cycles. Intermittent treatment is associated
with
fewer side effects and lower cost.
Hysterectomy is not effective for premenstrual syndrome as it
does not alter hormonal balance in people with a uterus.
Oophorectomy, however, is a potential surgical treatment for
severe refractory cases in those done with childbearing.
Spironolactone is a diuretic. It has been tested mainly to control
symptoms such as bloating, weight gain, and breast
tenderness. In studies, the effectiveness for treating these
symptoms is inconsistent. It has anti-androgenic effects but
offers less
control than hormonal options. If this were to be tried on a
patient, the dosing would be during the luteal phase. One must
be
cautious about causing potential electrolyte abnormalities, such
as hyperkalemia, with this medication.
Vitamin B6 has inconsistent data regarding effectiveness. It
may be effective for mild symptoms or in women reluctant to
use
antidepressants. Patients should be cautioned about overdosing
as this may cause peripheral neurotoxicity.
Other non-drug interventions include regular exercise and low
carbohydrate diets. Decreasing carbohydrates in the luteal phase
may be effective for mild symptoms. Relaxation therapy has
also been studied and shown some efficacy. These are all worth
discussing with patients, although true efficacy is not proven.
Progesterone-Releasing IUD Placement: Contraindications /
Complications

Contraindications: Infection or active gynecologic cancer,
allergy to levonorgestrel (uncommon)
Cautions: History of headache or vascular disease, history of
perforation with prior IUD placement, allergy to iodine or
shellfish
(often used to clean the cervix, other methods could be used).
Complications:
During the actual procedure, the patient can have pain or
bleeding. There is also a risk of uterine infection or perforation
which are
rare with appropriate technique. If a patient were to get
pregnant, they have a higher risk of an ectopic pregnancy and
this is an
emergency. Patients may also experience vasovagal symptoms
with placement. They should also be reminded that it is not
effective for protection from sexually transmitted infections.
After the procedure is done, the patient may have some bleeding
or cramping for a few days, but this usually responds to
ibuprofen. There may be foul-smelling vaginal discharge from
an infection.
Once the IUD is in place, there is a risk the uterus can expel it,
or the patient may have pain with intercourse or experience
irregular bleeding. Some partners can feel the string. After the
patient's next period, she should come back to have the string
checked and make sure it is still in place. It is a good idea for
the patient to check for the IUD strings after every menses to
ensure
it stays inside the uterus but to use caution that it is not
inadvertently removed. The strings can be trimmed at follow -up
visits if
needed.
The patient should return to the clinic for any fever associated
with lower abdominal pain, with or without abnormal vaginal

2022-03-30 22:44 EDT 5/10
discharge. These signs would be concerning for uterine
infection.
Studies
Evaluation of Differential of Secondary Dysmenorrhea /
Menorrhagia
A complete blood count is always a consideration when a person
seems to be bleeding more heavily than usual. Iron deficiency
anemia is common in patients of reproductive age, affecting
between 21% and 67% of those with menorrhagia. It can add to
the
fatigue a person feels. This type of anemia is responsive to
therapy, which initially is oral iron supplementation, and could
progress to iron infusions if indicated.
A pregnancy test should be done on every person with a uterus
of reproductive age with any changes in bleeding pattern or
amount. Ectopic pregnancy can present with irregular bleeding
and is life-threatening. Additionally, unusual forms of
pregnancy—
such as molar pregnancies—can cause heavy bleeding,
abdominal pain, and uterine enlargement. Although it is
acknowledged
that pregnancy most commonly causes amenorrhea, these are
diagnoses not to be missed.
Ultrasound is the study of choice for pelvic pathology. The
sensitivity is 60% and specificity is 93% for detecting
intracavitary
issues. The sensitivity for detecting intramural pathology is also
high, but not as high as it is for detecting intracavitary issues.
Ultrasound has a high positive predictive value for detecting

adenomyosis as well. It does not require any radiation to the
ovaries
(CT scans will), no intravenous dyes are needed, and it is
generally painless for the patient. The pelvic ultrasound does
require an
intravaginal portion, and all should be advised of this in
advance. This could be uncomfortable and can cause
psychological
distress if the patient does not realize this will be done or if
they have a history of trauma, particularly sexual trauma. The
combination of abdominal and vaginal ultrasounds allow for
reliable measurements and anatomy of the cervix, uterus, and
ovaries. Ultrasound is acceptable at the initial evaluation
whenever the physician thinks the patient has secondary
dysmenorrhea
based on clinical history and physical exam.
Thyroid disorders are easy to check for and easy to treat. The
fatigue and bowel symptoms of thyroid disease may also
overlap
with menstrual disorders, making the diagnosis easy to miss
unless you are looking for it. Thyroid disorders can also affect
the
frequency of menses and should be considered if other causes of
abnormal bleeding are excluded. Hypothyroidism is common in
people of reproductive age, particularly those assigned female
at birth. The American College of Obstetrics and Gynecology
has
not recommended this test for all initially without compelling
history. However, guidelines from the United Kingdom do
recommend thyroid testing.
Computed tomography (CT) scans have been studied but these
do not give a well-defined look at pelvic pathology and are not
routinely used for gynecologic problems. They may be used at
the end of a work-up for pelvic pain, but usually to look for
other,
non-gynecologic abdominal causes.

Magnetic resonance imaging (MRI) is being used more often in
diagnosing gynecologic pathology. It can give a better diagnosis
of
adenomyosis and locations of leiomyomas. MRI is able to more
accurately assess changes in tumor volume preoperatively. At
times it can provide better analysis of ovarian masses as well.
MRI is expensive and time-consuming, factors that must be
balanced with how useful the information obtained will be. MRI
is not used as an initial study for secondary dysmenorrhea or
menorrhagia.
Testing for von Willebrand disease should be considered in any
person with menorrhagia and other potential episodes of heavy
bleeding, such as postpartum hemorrhage. In the initial workup
of isolated dysmenorrhea, this is not recommended. However,
when dysmenorrhea is present with menorrhagia it should be
considered. Even though the American College of Obstetrics
and
Gynecology recommends testing for von Willebrand for any
women with severe menorrhagia, meta-analyses do not
demonstrate
this to be cost-effective in initial assessment. The one exception
is when menorrhagia occurs in an adolescent. Bleeding
disorders
more commonly present as menorrhagia from the beginning of
menses rather than starting 15 years after menarche. If
considering starting OCPs in an adolescent, one should order
the von Willebrand prior to initiation, as it may affect the
results.
Clinical Reasoning
Differential of Secondary Dysmenorrhea / Menorrhagia
More Common Diagnoses:

2022-03-30 22:44 EDT 6/10
Adenomyosis
Epidemiology: Occurs more frequently in parous than
nonparous people. Adenomyosis actually can be
found in any person with a uterus from adolescence to
menopause.
Pathophysiology: This is not completely understood. One theory
is endometrial invagination but has not
been completely proven. It is hypothesized that estrogen and
progesterone play a role only because
hormones can be treatment options.
Presentation: 60% of women complain of menorrhagia. The
uterus is typically enlarged and diffusely
boggy, but symmetric and should still be mobile. There may be
some urinary or gastrointestinal
symptoms secondary to size and mass effect on the bladder and
rectum.
Diagnosis: Ultrasound may demonstrate a heterogeneously
boggy uterus. MRI is more specific for
diagnosis.
Management: There is not currently any surgical method to
remove the discrete areas affected.
Hormonal contraception may help with symptoms in those who
desire future pregnancy, while uterine
artery embolization or hysterectomy may be performed in those
no longer desiring biological children.
Chronic pelvic

inflammatory
disease (PID)
Epidemiology: The exact incidence and prevalence is unknown.
Pathophysiology: PID can have a subclinical smoldering course
that is considered chronic. These
patients can have significant morbidities to include infertility
and pain in the lower abdomen. Many of
these cases will have plasma cells on endometrial biopsy.
Presentation: The cardinal symptom is lower abdominal pain,
usually unrelated to menses. However,
pain that occurs just prior to or during menses is highly
suggestive of dysmenorrhea. Menorrhagia is
seen in one-third of patients with chronic pelvic inflammatory
disease, especially subclinical disease
that isn't treated early.
Management: As with acute PID, workup should include testing
for sexually transmitted infections and
treatment covering chlamydia and gonorrhea if suspected or
diagnosed.
Endometriosis
Epidemiology: Endometriosis is a disorder that affects people of
reproductive age with a uterus. The
most common age affected is 25 to 35 years old. The exact
prevalence in the general population is
unknown. Risk factors include nulliparity, early menarche or
late menopause, short menstrual cycles,
and long menses. There may be protective factors that decrease
the likelihood of endometriosis. These
include multiparity, lactating, and late menarche.

Pathophysiology: Endometrial glands in areas other than the
uterus.
Presentation: Symptoms include dyspareunia, bowel or bladder
symptoms that cycle with menses,
fatigue, abnormal vaginal bleeding, and some effects on
fertility. Pain, either chronic pelvic pain or
dysmenorrhea, occurs in 75% of patients with endometriosis and
is the most common symptom.
Dyspareunia is a differentiating clinical factor: it is common in
those with endometriosis; it is rare with
leiomyoma. On physical exam, these patients have pain in the
pain cul-de-sac, immobile and
retroflexed uterus, nodules on the uterosacral ligaments, or just
pain with uterine motion.
Management: Symptoms may be controlled with methods
similar to those for menorrhagia. Hormonal
contraceptives may alleviate symptoms. Hysterectomy and
uterine artery embolization are less likely to
be effective as the tissue is outside of the uterus.
Uterine
leiomyomas
(commonly
called fibroids)
Epidemiology: Fibroids are the most common benign tumors of
the uterus. Decreased risk of developing
fibroids has been noted with oral contraceptive use, increasing
parity, and smoking. Increased risk is
known with early menarche, family history of fibroids, and
increased alcohol use. Although more
research needs to be done exploring the causes of fibroids that
include a more racially diverse pool,

there seems to be a disproportionately high rate of fibroid
development in African American women as
compared to other racial demographic groups. Disparities also
exist in the type of care that women
receive for their fibroids; for example, studies have shown that
Caucasian women are more likely to be
offered a laparoscopic procedure as compared to African
American and Hispanic women with the same
household income, indicating systemic disparities in care.
Pathophysiology: These are made of normal myometrial cells.
They can occur within the cavity and
under the endometrium (submucosal), within the myometrium
(intramural), on the serosal surface
(serosal), or in the cervix.
Presentation: Common symptoms of fibroids include pain,
pressure, and changes in menstruation.
Other related signs may be miscarriages, infertility, or an
enlarged uterus, and some may have no
symptoms at all. Work loss and quality of life can be issues.
The physical exam typically has an
enlarged uterus that is freely mobile. The uterus may feel
"knobby" from an irregular contour, and
occasionally be minimally tender on exam.
Management: NSAIDS, combined oral contraceptive pills,
levonorgestrel-releasing IUDs, depo-
medroxyprogesterone, and a variety of surgical options (e.g.,
hysterectomy, myomectomy) are among
the options.
Less Common Diagnoses:
2022-03-30 22:44 EDT 7/10

Cervical
stenosis
Cervical stenosis can be congenital or acquired. With congenital
stenosis, an adolescent will have
significant dysmenorrhea, which is not as responsive to
nonsteroidal anti-inflammatory medications as
would be expected. The menstrual flow will also be minimal.
Acquired stenosis may be related to
cryotherapy or LEEP procedures (performed for concerns of
cervical cancer on Pap tests and colposcopy
biopsies). This causes dysmenorrhea as the uterus is distended
with blood. On exam, the uterus will feel
diffusely enlarged.
Endometrial
adenocarcinoma
or endometrial
hyperplasia
Endometrial adenocarcinoma (cancer) may occur under age 40
(2%–14% of cases) but is less likely in this
age group. It does present with irregular bleeding, more often as
postmenopausal bleeding. It may or may
not cause dysmenorrhea. Endometrial hyperplasia is a non-
malignant process that can mimic endometrial
adenocarcinoma. It generally occurs in the perimenopausal or
menopausal period. It is due to unopposed
estrogen.
Inflammatory
bowel disease
Inflammatory bowel disease can often be misdiagnosed as a

gynecologic problem since constipation and
diarrhea are associated with premenstrual syndrome as well.
Additionally, when a person has bloody stools
during her menses, the clinical diagnosis can be more
confusing. However, when there is pain with
defecation and bloody stools occur at times other than during
menses this diagnosis becomes clearer.
Abnormal vaginal bleeding is not a typical symptom of
inflammatory bowel disease.
Irritable bowel
syndrome
Irritable bowel syndrome may cause crampy pain prior to and
during menses, but will also occur at other
times during the month. This pain is often associated with
diarrhea and/or constipation.
Leiomyosarcoma Leiomyosarcoma is an abnormal variant of a
smooth muscle tumor that can occur anywhere in the bodybut is
commonly in the abdomen. It is a rare type of cancer and
therefore less likely.
Ovarian cysts
Ovarian cysts commonly cause recurrent and chronic pelvic
pain. This type of pain is more likely to occur
mid-cycle, although the patient may have pain associated with
menses. This location of this pain is
typically in one of the lower quadrants and not as much midline.
Ovarian cysts may come and go related to
ovulation.
Mood disorders
or adjustment
disorders

Mood disorders or adjustment disorders can be exacerbated by,
but do not typically cause dysmenorrhea.
Dysmenorrhea is a real pain syndrome. If you treat a concurrent
mood disorder it can improve the pain
response.
Uterine polyps
Uterine polyps may be associated with abnormal bleeding—
specifically intermenstrual or postcoital
bleeding—but there will also be menorrhagia. Polyps do not
typically present with dysmenorrhea, but this
may occur later.
References
ACOG. The American College of Obstetricians and
Gynecologists. 2021. Marijuana and Pregnancy. Accessed April
6, 2021.
ACOG. The American College of Obstetricians and
Gynecologists. 2021. Uterine Fibroids. Accessed April 6, 2021.
Apgar BS, Kaufman AH, George-Nwogu U, Kittendorf A.
Treatment of menorrhagia. Am Fam Physician.
2007;75(12):1813-9.
Armour M, Ee CC, Naidoo D, et al. Exercise for
dysmenorrhoea. Cochrane Database Syst Rev.
2019;9(9):CD004142. Published 2019
Sep 20.
Balık G, Ustüner I, Kağıtcı M, Sahin FK. Is there a relationship
between mood disorders and dysmenorrhea?. J Pediatr Adolesc
Gynecol.
2014;27(6):371-4.

CDC. Centers for Disease Control and Prevention. Routine
Measles, Mumps, and Rubella Vaccination. Reviewed January
26, 2021.
Accessed April 6, 2021.
Carl J, Hill DA. Preconception counseling: make it part of the
annual exam. J Fam Pract. 2009;58(6):307-14.
Casey PM, Long ME, Marnach ML. Abnormal cervical
appearance: what to do, when to worry?. Mayo Clin
Proc.2011;86(2):147-51.
Cope E. Danazol in the treatment of menorrhagia. Drugs.
1980;19(5):342-8.
Dawood MY. Primary dysmenorrhea: advances in pathogenesis
and management. Obstet Gynecol. 2006;108(2):428-41.
De La Cruz MS, Buchanan EM. Uterine Fibroids: Diagnosis and
Treatment. Am Fam Physician. 2017;95(2):100-7.
Eltoukhi HM, Modi MN, Weston M, Armstrong AY, Stewart
EA. The health disparities of uterine fibroid tumors for African
American
women: a public health issue. Am J Obstet Gynecol.
2014;210(3):194-9.
Fadhlaoui A, Ben Hassouna J, Khrouf M, Zhioua F, Chaker A.
Endometrial adenocarcinoma in a 27-year-old woman. Clin Med
Insights
Case Rep. 2010;3:31-9.
2022-03-30 22:44 EDT 8/10
https://www.acog.org/womens-health/infographics/marijuana-

and-
pregnancy?utm_source=redirect&utm_medium=web&utm_camp
aign=otn
https://www.acog.org/womens-health/faqs/uterine-
fibroids?utm_source=redirect&utm_medium=web&utm_campaig
n=otn
https://pubmed.ncbi.nlm.nih.gov/17619523/
https://www.cdc.gov/vaccines/vpd/mmr/hcp/recommendations.ht
ml
Ferrero S, Abbamonte LH, Giordano M, Parisi M, Ragni N,
Remorgida V. Uterine myomas, dyspareunia, and sexual
function. Fertil Steril.
2006;86(5):1504-10.
Fisher WA, Black A. Contraception in Canada: a review of
method choices, characteristics, adherence and approaches to
counseling.
CMAJ. 2007;176(7):953-61.
Grigorieva V, Chen-Mok M, Tarasova M, Mikhailov A. Use of a
levonorgestrel-releasing intrauterine system to treat bleeding
related to
uterine leiomyomas. Fertil Steril. 2003;79(5):1194-8.
Grimes DA, Lopez LM, Manion C, Schulz KF. Cochrane

systematic reviews of IUD trials: lessons learned.
Contraception. 2007;75(6
Suppl):S55-S59.
Hay PE, Kerry SR, Normansell R, et al. Which sexually active
young female students are most at risk of pelvic inflammatory
disease? A
prospective study. Sex Transm Infect. 2016;92(1):63-6.
Huyck KL, Panhuysen CI, Cuenco KT, et al. The impact of race
as a risk factor for symptom severity and age at diagnosis of
uterine
leiomyomata among affected sisters. Am J Obstet Gynecol.
2008;198(2):168.e1-168.e1689.
Iacovides S, Avidon I, Baker FC. What we know about primary
dysmenorrhea today: a critical review. Hum Reprod Update.
2015;21(6):762-78.
James A, Matchar DB, Myers ER. Testing for von Willebrand
disease in women with menorrhagia: a systematic review.
Obstet Gynecol.
2004;104(2):381-8.
Johnson SR. Premenstrual syndrome, premenstrual dysphoric
disorder, and beyond: a clinical primer for practitioners. Obstet
Gynecol.
2004;104(4):845-59.
Levgur M. Diagnosis of adenomyosis: a review. J Reprod Med.
2007;52(3):177-93.
Lippman SA, Warner M, Samuels S, Olive D, Vercellini P,
Eskenazi B. Uterine fibroids and gynecologic pain symptoms in
a population-
based study. Fertil Steril. 2003;80(6):1488-94.

Magalhães J, Aldrighi JM, de Lima GR. Uterine volume and
menstrual patterns in users of the levonorgestrel-releasing
intrauterine
system with idiopathic menorrhagia or menorrhagia due to
leiomyomas. Contraception. 2007;75(3):193-8.
Mansy, AA. Does sublingual misoprostol reduce pain and
facilitate IUD insertion in women with no previous vaginal
delivery? A
randomized controlled trial. Middle East Fertility Society
Journal. 2018;23(1):72–6.
Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical
therapy for heavy menstrual bleeding. Cochrane Database Syst
Rev.
2006;(2):CD003855. Published 2006 Apr 19.
Meredith SM, Sanchez-Ramos L, Kaunitz AM. Diagnostic
accuracy of transvaginal sonography for the diagnosis of
adenomyosis:
systematic review and metaanalysis. Am J Obstet Gynecol.
2009;201(1):107.e1-107.e1076.
Morrow C, Naumburg EH. Dysmenorrhea. Prim Care.
2009;36(1):19-vii.
Proctor M, Farquhar C. Diagnosis and management of
dysmenorrhoea. BMJ. 2006;332(7550):1134-8.
Proctor ML, Latthe PM, Farquhar CM, Khan KS, Johnson NP.
Surgical interruption of pelvic nerve pathways for primary and
secondary
dysmenorrhoea. Cochrane Database Syst Rev.
2005;(4):CD001896. Published 2005 Oct 19.

Proctor ML, Roberts H, Farquhar CM. Combined oral
contraceptive pill (OCP) as treatment for primary
dysmenorrhoea. Cochrane
Database Syst Rev. 2001;(4):CD002120.
Reid RL. Premenstrual Dysphoric Disorder (Formerly
Premenstrual Syndrome). In: Feingold KR, Anawalt B, Boyce
A, et al., eds.
Endotext. South Dartmouth (MA): MDText.com, Inc.; January
23, 2017.
Saslow D, Solomon D, Lawson HW, et al. American Cancer
Society, American Society for Colposcopy and Cervical
Pathology, and
American Society for Clinical Pathology screening guidelines
for the prevention and early detection of cervical cancer. J Low
Genit
Tract Dis. 2012;16(3):175-204.
Savaris RF, Fuhrich DG, Maissiat J, Duarte RV, Ross J.
Antibiotic therapy for pelvic inflammatory disease. Cochrane
Database of
Systematic Reviews. 2020, Issue 8. Art. No.: CD010285.
Shapley M, Jordan K, Croft PR. An epidemiological survey of
symptoms of menstrual loss in the community. Br J Gen Pract.
2004;54(502):359-63.
Sharghi M, Mansurkhani SM, Larky DA, et al. An update and
systematic review on the treatment of primary dysmenorrhea.
JBRA Assist
Reprod. 2019;23(1):51-7. Published 2019 Jan 31.
Shimabukuro TT, Kim SY, Myers TR, et al. Preliminary
Findings of mRNA Covid-19 Vaccine Safety in Pregnant
Persons [published online

ahead of print, 2021 Apr 21]. N Engl J Med.
2021;10.1056/NEJMoa2104983.
Smorgick N, As-Sanie S. Pelvic Pain in Adolescents. Semin
Reprod Med. 2018;36(2):116-22.
Society of Obstetricians and Gynaecologis ts of Canada. SOGC
clinical practice guidelines. Uterine fibroid embolization (UFE).
Number
150, October 2004. Int J Gynaecol Obstet. 2005;89(3):305-18.
Turok DK, Gero A, Simmons RG, et al. Levonorgestrel vs.
Copper Intrauterine Devices for Emergency Contraception. N
Engl J Med.
2021;384(4):335-44.
Vannuccini S, Petraglia F. Recent advances in understanding
and managing adenomyosis. F1000Res. 2019;8:F1000 Faculty
Rev-283.
Published 2019 Mar 13.
Walker HK, Hall WD, Hurst JW, eds. Clinical Methods: The
History, Physical, and Laboratory Examinations. 3rd ed.
Boston:
2022-03-30 22:44 EDT 9/10

https://www.sciencedirect.com/science/article/pii/S1110569017
301243?via%253Dihub
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.C
D010285.pub3/references?cookiesEnabled
Butterworths; 1990.
2022-03-30 22:44 EDT 10/10
Family Medicine 32: 33-year-old with painful cyclesLearning
ObjectivesKnowledgePrimary Dysmenorrhea Definition,
Prevalence, and Risk FactorsGenderGender and Sexual Identity
QuestionsQuestioning About Reproductive HistoryNormal
Pelvic Exam FindingsMenorrhagiaPremenstrual Dysphoric
Disorder DSM-5 Diagnostic CriteriaPreconception
CounselingSafety and Mental HealthManagementPrimary

Dysmenorrhea: Presentation and TreatmentTreatment for
Leiomyomas and Associated SymptomsHormonal Birth Control
TherapiesPremenstrual Syndrome TreatmentProgesterone-
Releasing IUD Placement: Contraindications /
ComplicationsStudiesEvaluation of Differential of Secondary
Dysmenorrhea / MenorrhagiaClinical ReasoningDifferential of
Secondary Dysmenorrhea / MenorrhagiaMore Common
Diagnoses:Less Common Diagnoses:References

1Organ donationStudent’s nameI

Recommended

Recommended

More Related Content

More from TatianaMajor22

More from TatianaMajor22 (20)

Recently uploaded

Recently uploaded (20)

1Organ donationStudent’s nameI